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” EXPEDITED STATE HEARING REQUEST BEFORE THE DEPARTMENT OF SOCIAL SERVICES I, the undersigned, hereby request an expedited hearing against the county of __________________________________ for the county action\/inaction regarding: Please check the box that applies to you Program CWD Action CalWORK Immediate Need CalFresh\/Food Stamp Expedited Services CalWORKs Homeless Assistance Immediate medical assistance Child Care needed to work or attend school Books needed to not drop classes Transportation needed to work or attend school Other: Please Specify ______________________________________ ______________________________________ ______________________________________ ________________________________ ________________________________ ________________________________ Claimant and Representative Information ________________________________________________________________________ Claimant Name Last Name Case #\/SSN# ________________________________________________________________________ Claimant Address ________________________________________________________________________ Claimant Phone Number Email Address I want to have the person below represent me at this hearing: ________________________________________________________________________ Name of Authorized Representative Name of Organization, if any ________________________________________________________________________ Authorized Representative Address ________________________________________________________________________ Authorized Representative Phone Number Email Address ____________________________________________________________ ______________________ Claimant Signature Date for the county actioninaction regarding: Program: CWD ActionCalWORK Immediate Need: CWD ActionCalFreshFood Stamp Expedited Services: CWD ActionCalWORKs Homeless Assistance: CWD ActionImmediate medical assistance: CWD ActionChild Care needed to work or attend school: CWD ActionBooks needed to not drop classes: CWD ActionTransportation needed to work or attend school: Other Please Specify 1: Other Please Specify 2: Other Please Specify 3: 1: 2: 3: Claimant: Name: Last Name: Case SSN: Claimant Address: Claimant_2: Phone Number: Email Address: Name of Authorized Representative: Name of Organization if any: Authorized Representative Address: Authorized Representative: Phone Number_2: Email Address_2: undefined_8: Check Box1: Off Check Boxar: Off Check Box2: Off Check Box3: Off 4134: Off Check5: Off Check Box6: Off qergv2: Off Check Box1=4: Off ”

” FOR ASSISTANCE CONTACT CCWRO @ 1111 Howe Avenue, Suite 635, Sacramento, CA 95825 Tel. 916-736-0616 Email: [email protected] How to get copy of a state hearing tape? DSS POLICY: DSS will provide a copy of the hearing tape free of charge once the hearing decision has been released. DSS requests that claimants and their authorized representatives write to: DSS, SHD State Hearings Support Section P.O. box 944243, M.S. 9-17-37 Sacramento, CA 95814 or Email it to:[email protected] The request for a hearing tape must include the following information: Name of the Claimant ___________________________________ State Hearing # ___________________________________ Date of the Hearing ___________________________________ Name of the Judge ___________________________________ Requestor information if different than the claimant Name ______________________________________________ Agency ______________________________________________ Address ______________________________________________ City __________________________ ZIP ________________ Date: Requestor Signature Agency: Address: City: ZIP: Name: Name12: Name13: Name14: date: Namemlnlkjn: ”

” STATE OF CALIFORN IA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES WITHDRAWAL CONDITIONAL WITHDRAWALS OF REQUEST FOR HEARING I, , the undersigned do hereby: Withdraw my request for a state hearing before the State Department of Social Services. I understand that by withdrawing my request, I lose my right to a hearing on that request. I also understand that by withdrawing my request for hearing, aid which has been paid because of the request will stop without further notice. I may, however, file a new hearing request raising the identical issue provided that the new request is timely per Manual of Policies and Procedures Section 22-009. Conditionally withdraw my request for a state hearing before the State Department of Social Services. I understand that by conditionally withdrawing my request for hearing, aid which has been paid because of the hearing request will stop without further notice. I understand that the county will issue a redetermination notice within 30 days and that I must request a hearing within 90 DAYS of the county’s notice if I am not satisfied with the county’s reconsideration of my case. Upon such renewal, I shall have the same rights I would have had if I had not signed this conditional withdrawal. NOTE: A conditional withdrawal must provide that the actions of both parties will be completed within 30 days. The reasons for or conditions of this withdrawal are: Signed Signed (County Representative) (Claimant) (County Address) (City) (Telephone Number) (Zip Code) (Date) (Date) (Zip Code)(City) (Address) (Telephone Number) NOTE: A Conditional Withdrawal must also be signed by a County Representative or it is invalid. DPA 315 (7\/99) County Case No: Filing Date: Hearing Date: Hearing Time: Case Name: State Hearing No: County: box 1: Off case name: state hearing no: county: county case no: filing date: hearing date: hearing time: name 1: box 2: Off box 3: Off box 4: Off reason ln 1: reason ln 2: reason ln 3: reason ln 4: reason ln 5: reason ln 6: date signed 1: date signed 2: claimant address: county address: city\/state: city\/state 2: zip code: zip code 2: phone number 1: phone number 2: ”